Provider Demographics
NPI:1851356158
Name:NELSON, NICOLE (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5921 SUNNY LN
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9606
Mailing Address - Country:US
Mailing Address - Phone:262-376-0142
Mailing Address - Fax:
Practice Address - Street 1:10602 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5079
Practice Address - Country:US
Practice Address - Phone:262-241-8030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40443500Medicaid
WI40443500Medicaid
WI0028Medicare ID - Type Unspecified